Lesson Aim

From speaking to our community of practitioners, we learnt that many of you wanted a handy reference guide that summarises advanced testing options for health conditions.

In light of this, our Clinical Support Specialist, Virginia Blake, has written a clinically robust introduction to advanced testing options for Hashimoto’s Autoimmune Thyroiditis.

Read and refer to the below if ever you are looking for a starting point for advanced testing options for Hashimoto’s Autoimmune Thyroiditis.

Learning Objectives

• What is Hashimoto's Autoimmune Thyroiditis?
• How frequent is Hashimoto's?
• What causes Hashimoto's?
• The 3 stages of Hashimoto's development
• The role of thyroid peroxidase and thyroglobulin antibodies in the development of Hashimoto's
• What are the symptoms of Hashimotos?
• What triggers and exacerbates Hashimoto's?
• Recommended functional tests to assess Hashimoto's

What is Hashimoto's Autoimmune Thyroiditis?

Hashimoto's thyroiditis is caused by the immune system attacking Hashimoto's thyroiditis is caused by the immune system attacking the thyroid gland, which causes damage, reducing function. As the disease progresses, there may also be swelling of the gland. As the thyroid is destroyed over time, it's unable to produce enough thyroid hormone. This leads to symptoms of an underactive thyroid gland (hypothyroidism), such as tiredness, weight gain and dry skin. The swollen thyroid may also cause a goitre (lump) to form in the throat. It may take months or even years for the condition to be detected because it progresses very slowly (NHS, 2023).

How frequent is Hashimoto's?

Hashimoto’s autoimmune thyroiditis accounts for around 90% of underactive thyroid diagnoses in the developed world. It can be diagnosed quite late into the disease. This is because thyroid function may appear normal on test results despite the patient feeling that there is something wrong and having symptoms, often over a period of many years, diagnosis can take 5 to 15 years from first symptom onset. (Aijan & Weetman, 2015). The incidence of the condition is estimated at 0.8 in 1000 men and 3.5 in 1000 women (Pyzik et al., 2015).

Standard thyroid function tests in primary care do not assess autoimmune reactivity as a matter of course. Testing for antibodies is not a first line recommendation in the NHS and monitoring of antibodies is not recommended (NICE, 2021).

What causes Hashimoto's?

Recent research shows that the condition's development depends on three factors:

• an immune defect (e.g. a lower number of Tregs cells and altered protein and receptor expression on these Tregs)
• genetic susceptibility
• and an environmental trigger (Hu et al., 2019)

The 3 stages of Hashimoto's development

As with all autoimmune illness, there are 3 stages in the development of Hashimoto's:

Silent Autoimmunity: the patient experiences elevated thyroid peroxidase antibodies (TPOAb) and/or thyroglobulin antibodies (TgAb) with no symptoms or loss of tissue.

Autoimmune Reactivity: the patient experiences elevated TPOAb and or TgAB with symptoms and normal TSH levels.

Autoimmune Disease: the patient experiences elevated antibodies with symptoms, measurable tissue destruction, and elevated TSH.

The role of thyroid peroxidase and thyroglobulin antibodies in the development of Hashimoto's

Thyroid peroxidase (TPO) is the enzyme in the thyroid that facilitates the production of thyroid hormone (Boron & Boulpaep, 2003) .

Thyroglobulin (Tg) is the base protein from which thyroid hormones are made (Boron & Boulpaep, 2003).

For diagnosis of Hashimoto’s thyroiditis, TPO antibodies (Ab) are more relevant than TgAb. TgAb are found in approximately 10% of women. TgAb are also found in many other conditions – present in 50% of Grave’s disease, 20% of thyroid cancer and non-toxic goitere. They can also be found in autoimmune diseases not related to thyroid, such as coeliac disease, type 1 diabetes, Sjogren’s and myasthenia gravis. (Soh & Aw, 2019). Clinically, increased levels of TgAb with in range TPOAb should still be addressed.

Along-side the damage to thyroid tissue, the inflammation results in down regulation of 5’deiodinase and reduced conversion of T4 to T3. Inflammatory cytokines, free radicals and dysregulated hormones such as super oxide anion, hydroxyl radical, hydrogen peroxide and peroxynitrite; increasing production of leptin, TNF-alpha IL1, IL6, interferon gamma, and free fatty acids all work to reduce conversion of T4 to T3 (Mancini et al., 2016).

Inflammatory cytokines also disrupt docking of T3 hormone to target cell. This can explain normal lab results but presence of hypothyroid symptoms. Circulating hormones are in range, but are not attaching to their target cell (Boelen et al., 2011)

What are the symptoms of Hashimotos?

As thyroid hormone has system wide effects, there are many and varied Hashimoto’s symptoms. However, the most commonly reported symptoms with normal thyroid function tests in clinic are:

• general fatigue
• poor work out ability, work out recovery
• depression and poor brain function
• insomnia
• anxiety
• chronic constipation
• IBS
• dismissed symptoms reported in primary care setting (the "its all in your head diagnosis")

The following symptoms (Amino 1988) may also be present with normal thyroid function tests and also once the antibodies have triggered damage that registers with raised TSH levels:

• dry hair
• puffy face
• constipation
• depression
• eyebrow thinning
• enlarged thyroid
• slow heart rate
• cold intolerance
• dry skin
• fatigue
• forgetfulness
• menstrual disorders
• infertility
• muscle aches
• weight gain
• brittle nails
• cracked heels

In clinic, when assessing fatigue, infertility or mental health disorders, thyroid autoimmunity should be ruled out. Also, consider thyroid dysfunction in common digestive disorders seen in the NT clinic.

What triggers and exacerbates Hashimoto's?

Once autoimmune thyroid is found, the key aim for the nutritional therapist to focus on to find the condition's underlying trigger, and factors that contribute to on-going inflammation (mediators).

A full case history and then deciding on the appropriate test, targets the anti-inflammatory strategy. This should increase T4 to T3 conversion and increase T3 docking to receptors in target cells, thus exerting the desired effect of this master hormone.

Below summarises currently understood triggers and mediators:

Dietary Proteins

• Gluten (Virili et al., 2012)
• Sodium (Wen et al., 2016)
• Iodine (Zaletel & Gaberscek, 2011)
• Lectins (Vojdani et al., 2020)
• Decreased dietary diversity (Ishaq et al., 2017)
• Dietary protein cross-reactivity (Kharrazian et al., 2017)
• Pro-inflammatory diet Grains Casein Albumin (Kharrazian et al., 2017)

Lifestyle Factors

• Insomnia (Radomski et al., 2021)
• Sedentary lifestyle (Radomski et al., 2021)
• Overtraining (Radomski et al., 2021)
• Alcohol (Dong & Fu, 2014)
• Drug use (Radomski et al., 2021) 
• Lack of rest (Radomski et al., 2021)
• Stress (Markomanolaki et al., 2021)

Chemicals

• Bisphenol A (Somogyi et al., 2016)
• Pesticides (Leeman et al. 2019)
• Air pollution
• Fire retardants
• Benzene
• PCBs PBDE Perchlorate
• (Benvenga et al., 2015)
• Mercury (Rezaei et al., 2019)

Pathogens

• H Pylori (Figura et al. 1999; Figura et al. 2019)
• Toxoplasma Gondii (Tozzoli et al. 2008)
• Yersinia Enterocolitica (Chatzipanagiotou et al., 2001)
• Candida albicans (Vodjani et al. 1996)
• Epstein-Barr virus (Mori & Yoshida, 2010)
• Cytomegalovirus (Mori & Yoshida, 2010)
• Herpes-virus -6 (Mori & Yoshida, 2010)
• Parvovirus B-19 (Mori & Yoshida, 2010)
• Hepatitis C (Mori & Yoshida, 2010)
• Clostridium Botulinum (Gregoric et al., 2010)
• Borrelia Burgdorferi (Benvenga et al., 2004)
• Sars-Cov2 (Vojdani & Kharrazian, 2020)

Recommended functional tests to assess Hashimoto's

We recommend conducting a thorough case review with your patient/client to determine which functional test(s) to use to assess for Hashimoto's.

Please note, if you are a registered practitioner with Regenerus Labs, our Clinical Support Team can also advise on the appropriate test/s for your patient.

To assess thyroid function

We currently offer a range of advanced thyroid tests.

• The Functional Platinum Panel by Medical Diagnosis is an excellent all round test. It provides a comprehensive insight into: full blood count, biochemistry, endocrinology, haematology, and immunology. It also assesses vitamin B12, calcium iron including ferritin, TIBC, folate and homocysteine, thyroid function markers and thyroperoxidase and thyroglobulin antibodies.

Our full range of thyroid tests can be found here.

To assess for pathogens

Stool Testing (for pathogens and for digestive function):

• GI360 by Doctor's Data: provides pathogen, parasite, virus, commensal PCR, expanded parasitology, microscopy, bacterial and fungal cultures, digestive markers, inflammatory markers and microbiome and gut health markers. 
  
  
• Comprehensive Stool Analysis by Doctor's Data: this test delivers the same as the above but without PCR 
  
  

• H.Pylori add-on by Doctor's Data: detects H.pylori antigens in the stool
  

Our full range of stool tests can be found here.

To detect and assess chemical exposure

Metal toxicity

Regenerus Labs works with a range of specialist labs that facilitate functional testing to assess metal toxicity.

Quicksilver Scientific: Regenerus Labs is proud to be the UK's preferred supplier for Quicksilver Scientific. Quicksilver Scientific is a leading advanced functional testing and supplement laboratory that specialises in metal detoxification. Some of their metal toxicity testing options are:

• Mercury Tri Test: assesses hair, blood and urine to determine the magnitude of mercury burden, the source of exposure as well as the body's ability to excrete each form of mercury
  
  
• Blood Metals Test: screens for 16 metals - a broad range of nutrient and toxic metals to show elevated exposure to toxic metals or imbalances of nutrtient metals in whole blood

Doctor's Data: Regenerus Labs is proud to be the UK's preferred supplier for Doctor's Data. Doctor's Data specialise in essential and toxic elemental advanced functional testing. Some of their metal toxicity testing options are:

• Faecal Metals: provides a comprehensive evaluation of environmental exposure, potential for accumulation in the body (Hg), and possibly endogenous detoxification of potentially toxic metals
  
  
• Urine Toxic Metals: can be used to evaluate exposure to potentially toxic elements.
  
  
• Hair Toxic & Essential Elements: analyses metal toxicity exposure 10 different metals

Note: Book a support session with the Clinical Support Team to decide the best method to measure difference analytes. For example, aluminium is better measured via urine.

Environmental Pollutants

Regenerus Labs works with a range of specialist labs that facilitate functional testing to assess environmental pollutants.

Great Plains Laboratory: Great Plains Laboratory are specialists in metabolic, nutritional, and toxicity testing. They have a range of tests that assess for environmental pollutants covering chemicals, mold, metals, plastics, petrochemicals, fertilisers and more.

• MycoTOX: the MycoTOX is the most comprehensive and competitively priced mycotoxin test available screens for eleven different mycotoxins, from 40 species of mold, in one urine sample
  
  
• GPL-TOX: the GPL-TOX screens for 173 different environmental pollutants using 18 different metabolites, all from a single urine sample
  
  
• Glyphosate: the glyphosate assesses the IgG response to 190 foods common in the Western, Asian, and Mediterranean diets
  
  
• EnviroTox Complete: Great Plains Lab's most comprehensive environmental toxins panel, combining the GPL-TOX, MycoTox, OAT and Glyphosate tests.

Another environmental pollutant test thats popular amoungst our practitioner base is:

• Array 11: Chemical Immune Reactivity Screen by Cyrex Labs: The Array 11 is the first test to measure the actual immune response to chemicals, instead of simply detecting the level of chemical exposure/load which excretes from the body. It does this by using a breakthrough technology that identifies immune responses to chemicals bound to human proteins.

To assess for food allergies and sensitivity

Regenerus Labs facilitates a wide range of allergy and sensitivity tests from many advanced testing labs. Below are a few that are popular with our practitioner community.

• P88 Dietary Antigen Test by Precision Point Diagnostics: measures IgE, IgG4, IgG and complement (C3d) reactions to 88 commonly eaten foods
  
  
• Array 3: Wheat Proteome Reactivity and Autoimmunity by Cyrex Labs: tests for what is termed the gluten proteome, which are the various protein fragments of gluten that can trigger immune reactions in the body. This is very helpful test if conventional celiac testing is negative despite clinical suspicion for gluten sensitivity.
  
  
• Array 4: Gluten Associated Cross Reactive Foods and Food Sensitivity by Cyrex Labs: examines sensitivity to additional dietary proteins and foods that cross-react with gluten. This test can help identify other foods a patient is intolerant to and may need to eliminate from their diet.
  
  
• Cyrex Array 10: Multiple Food Immune Reactivity Screen by Cyrex Labs: This panel measures reactivity to 180 food antigens in the cooked, raw, modified or processed form on the same panel. Assists in early detection of dietary-related triggers of autoimmune reactivity and monitors the effectiveness of customized dietary protocols
  

References

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